Peyronie Disease Society Topical Verapamamil survey

              peyronies disease society

Survey on Topical or Transdermal Verapamil

This survey is only for those that have had used some form of topical or transdermal Verapamil for at least 60 days.

This information will be used to inform patients and urologists.

No identifying information will be released on this survey.

Please take this survey only once!

1.  Have you ever used topical or transdermal Verapamil (TV) for at least 60 days?

      Yes
     No

IF YES, Continue

2. Following your period of treatment with TV, did you have any permanent changes in your curve, bend, or indentation?

   Select 1
Greatly Improve
    Moderately improve
    Slightly Improve
      No Change
    Slightly Worsen
    Moderately Worsen
     Greatly Worsen

3. Following your period of treatment with TV, did you have any permanent changes in your erect length or girth?

    Select 1
Greatly Improve
    Moderately improve
Slightly Improve
      No Change
    Slightly Worsen
    Moderately Worsen
      Greatly Worsen

4. Following your period of treatment with TV, did you have any permanent changes in erections?

    Select 1
    Greatly Improve
    Moderately improve
Slightly Improve
      No Change
    Slightly Worsen
    Moderately Worsen
      Greatly Worsen

5. How long did you have PD prior to starting the topical Verapamil ?

     Select 1
       1 to 6 months
       6 to 12 months
       12 to 18 months
       18 to 24 months
       greater than 24 months

6.    How long did you use topical verapamil?

      Select 1
       2-3 months
     4-6 months
     7-9 months
   10-12
     More than 12

7. How diligent were you in following directions and frequency of use?

         I strictly followed the schedule for applying the TV
         I was reasonably good about following the schedule
         I was pretty casual about following the schedule TV

8. What was the source of the topical Verapamil
        PDLabs
        Talon (Sheppherd)
        Other

9. How long did your source tell you it takes before you notice ANY KIND OF results from their medication?

     write in answer

10. To validate the integrity of this survey, please type your forum screen name (only for PDS members)
      (This is only to assure the survey is only filled out once and to validate member participation. (This piece of information
      will not be released or made public)

11. During the same time that you used TV were you using any other prescribed or alternative treatments?

Yes
No

If yes, list the other treatments you were using and any other comments below:

Thank You for supporting our efforts by participating in this survey.

After submitting the survey, return to this page and click a link at the bottom of this page.